Brazilian Ministry of Health, Pan American Health Organization, and Enhancing Research Activity in Epidemic Situations.

Background Since 2015, the arthropod-borne viruses (arboviruses) Zika and chikungunya have spread across the Americas causing outbreaks, accompanied by increases in immune-mediated and infectious neurological disease. The spectrum of neurological manifestations linked to these viruses, and the importance of dual infection, are not known fully. We aimed to investigate whether neurological presentations differed according to the infecting arbovirus, and whether patients with dual infection had a different disease spectrum or severity. Methods We report a prospective observational study done during epidemics of Zika and chikungunya viruses in Recife, Pernambuco, a dengue-endemic area of Brazil. We recruited adults aged 18 years or older referred to Hospital da Restauração, a secondary-level and tertiary-level hospital, with suspected acute neurological disease and a history of suspected arboviral infection. We looked for evidence of Zika, chikungunya, or dengue infection by viral RNA or specific IgM antibodies in serum or CSF. We grouped patients according to their arbovirus laboratory diagnosis and then compared demographic and clinical characteristics. Findings Between Dec 4, 2014, and Dec 4, 2016, 1410 patients were admitted to the hospital neurology service; 201 (14%) had symptoms consistent with arbovirus infection and sufficient samples for diagnostic testing and were included in the study. The median age was 48 years (IQR 34–60), and 106 (53%) were women. 148 (74%) of 201 patients had laboratory evidence of arboviral infection. 98 (49%) of them had a single viral infection (41 [20%] had Zika, 55 [27%] had chikungunya, and two [1%] had dengue infection), whereas 50 (25%) had evidence of dual infection, mostly with Zika and chikungunya viruses (46 [23%] patients). Patients positive for arbovirus infection presented with a broad range of CNS and peripheral nervous system (PNS) disease. Chikungunya infection was more often associated with CNS disease (26 [47%] of 55 patients with chikungunya infection vs six [15%] of 41 with Zika infection; p=0·0008), especially myelitis (12 [22%] patients). Zika infection was more often associated with PNS disease (26 [63%] of 41 patients with Zika infection vs nine [16%] of 55 with chikungunya infection; p≤0·0001), particularly Guillain-Barré syndrome (25 [61%] patients). Patients with Guillain-Barré syndrome who had Zika and chikungunya dual infection had more aggressive disease, requiring intensive care support and longer hospital stays, than those with mono-infection (median 24 days [IQR 20–30] vs 17 days [10–20]; p=0·0028). Eight (17%) of 46 patients with Zika and chikungunya dual infection had a stroke or transient ischaemic attack, compared with five (6%) of 96 patients with Zika or chikungunya mono-infection (p=0·047). Interpretation There is a wide and overlapping spectrum of neurologica...

RESUMO: Introdução: A tuberculose (TB) é um dos graves problemas da saúde pública mundial. A vigilância epidemiológica tem se mostrado uma importante ferramenta para auxiliar em ações de controle e prevenção de doenças transmissíveis, como a TB e a aids. O objetivo do presente estudo foi estimar a proporção e os fatores associados à subnotificação da tuberculose em Pernambuco, entre os casos de coinfecção TB/aids, com base nos dados do Sistema de Informação de Agravos de Notificação da TB e da aids. Métodos: Realizou-se um estudo de corte seccional, baseado nos registros dos Sistemas de Notificação de TB e aids, para identificação de casos de subnotificação de TB no período de estudo, mediante a realização de linkage probabilístico utilizando o software RecLink III. Resultados: Verificou-se proporção de 29% de subnotificação de TB, e os fatores associados à subnotificação foram: apresentar forma clínica da TB pulmonar cavitária ou não especificada, ou ter os dois tipos de TB ao mesmo tempo; e ser atendido fora do Recife e em serviços que não são especializados para vírus da imunodeficiência humana (HIV)/aids. Discussão: A proporção de subnotificação encontrada em nosso estudo foi menor do que a observada em outras pesquisas brasileiras que levaram em consideração a subnotificação haja vista os dados de mortalidade. Conclusão: As variáveis associadas à subnotificação de TB referem-se, em sua maioria, à rede de atenção, e não às características individuais, o que aponta para a necessidade de capacitação dos profissionais de saúde para efetuar a notificação aos sistemas de informação.

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ObjectiveTo identify the incidence of and risk factors for tuberculosis in people living with HIV (PLHIV).DesignObservational, prospective cohort study.MethodsA total of 2069 HIV-infected patients was observed between July 2007 and December 2010. The Kaplan-Meier method was used to estimate the probability of survival free of tuberculosis, and Cox regression analysis to identify risk factors associated with the development of tuberculosis.ResultsSurvival free of tuberculosis (TB) was 91%. The incidence rate of tuberculosis was 2.8 per 100 persons/years. Incidence of tuberculosis was higher when subjects had CD4 cell count <200 cells/mm3; were not on antiretroviral therapy; in those who had, a body mass index <18.5 kg/m2, anemia (or were not tested for it), were illiterate or referred previous tuberculosis treatment at entry into the cohort. Those not treated for latent TB infection had a much higher risk (HR = 7.9) of tuberculosis than those with a negative tuberculin skin test (TST). Having a TST≥5 mm but not being treated for latent TB infection increased the risk of incident tuberculosis even in those with a history of previous tuberculosis.ConclusionsPreventive actions to reduce the risk of TB in people living with HIV should include an appropriate HAART and treatment for latent TB infection in those with TST≥5 mm. The actions towards enabling rigorous implementation of treatment of latent TB infection and targeting of PLHIV drug users both at the individual and in public health level can reduce substantially the incidence of TB in PLHIV.

Despite the effectiveness of combination antiretroviral therapy in the treatment of people living with HIV/AIDS (PLWHA), nonadherence to medication has become a major threat to its effectiveness. This study aimed to estimate the prevalence of self-reported irregular use of antiretroviral therapy and the factors associated with such an irregularity in PLWHA. A cross-sectional study of PLWHA who attended two referral centers in the city of Recife, in Northeastern Brazil, between June 2007 and October 2009 was carried out. The study analyzed socioeconomic factors, social service support and personal habits associated with nonadherence to antiretroviral therapy, adjusted by multivariable logistic regression analysis. The prevalence of PLWHA who reported irregular use of combination antiretroviral therapy (cART) was 25.7%. In the final multivariate model, the irregular use of cART was associated with the following variables: being aged less than 40 years (OR = 1.66, 95%-CI: 1.29-2.13), current smokers (OR = 1.76, 95%-CI: 1.31-2.37) or former smokers (OR = 1.43, 95%-CI: 1.05-1.95), and crack cocaine users (OR = 2.79, 95%-CI: 1.24-6.32). Special measures should be directed towards each of the following groups: individuals aged less than 40 years, smokers, former smokers and crack cocaine users. Measures for giving up smoking and crack cocaine should be incorporated into HIV-control programs in order to promote greater adherence to antiretroviral drugs and thus improve the quality of life and prolong life expectancy.

BackgroundTuberculosis (TB) is the leading cause of death related to HIV worldwide. This study analyzes the survival of People Living with HIV (PLHIV) reporting cough without bacteriological confirmation of TB and identify factors associated with death.MethodsProspective cohort with a consecutive sample of PLHIV, aged ≥ 18 years. Patient inclusion criteria were complaint of current cough of any duration at the time of the first study interview or during their subsequent routine visits to health services and for whom AFB sputum smear was either negative or not performed during the whole follow-up period. Kaplan-Meier method was used to calculate the probability of survival. We estimated the Hazard Ratio (HR) in bivariate and multivariate Cox regression analyses.ResultsMortality was 4.6 per 100 py; 73% were receiving HAART at recruitment. Average time from the first recorded date of cough until empirical treatment for tuberculosis was six months. Mortality was higher when the CD4 count was low (HR = 5.3; CI 95%: 3.2-9.0; p = 0.000), in those with anemia (HR = 3.0; CI 95%: 1.6-5.6; p = 0.001) and with abnormal chest X-rays (HR = 2.4; CI 95%: 1.4-4.0; p = 0.001). Mortality was higher in those receiving empirical TB treatment (HR = 2.4; CI 95%: 1.4-4.0; p = 0.002), but only in those with normal X-rays, no history of tuberculosis and no bacteriology requests. Empirical treatment for TB was more frequent in PLHIV with low CD4 counts, anemia, history of opportunistic infections, weight loss, previous tuberculosis, negative bacteriology test (as opposed to not having a test) and abnormal chest X-ray.ConclusionsHigher mortality in PLHIV reporting a current cough without bacteriological confirmation of tuberculosis was identified for those with a CD4 cell count <200, abnormal chest X-ray, anemia and empirical treatment for tuberculosis. Mortality was not significantly higher in those empirically treated for TB, who had three characteristics suggestive of the disease (abnormal chest X-ray, history of TB treatment, AFB sputum smear or M.tb culture testing). Routine cohorts are not an adequate setting to evaluate the impact of empirical treatment for TB on the mortality of PLHIV.

Astaxanthin is a carotenoid antioxidant reported to have beneficial effects on animals, including immune response and reproductive function. This study aimed to determine the effect of daily supplementation of dairy cows with astaxanthin on leukocyte population and oocyte developmental potential in summer. Lactating Holstein cows (n=45) from a compost barn in Paraná, Brazil, received 0 (control), 0.25 (low AST), or 0.5 (high AST) mg/kg per day of astaxanthin for 75 days in the summer (January to March 2020). Groups were homogeneous according to parity, days in milk, and milk yield. Blood cell count (white blood cells, lymphocyte, neutrophil, monocyte, basophil, and eosinophil) was performed on sodium citrate-treated blood samples collected every 14 days. Ovum pickup (OPU) was then conducted three times at a 20-day interval and oocytes underwent IVF to assess their developmental competence. Data were tested for normality of residues (Shapiro-Wilk test) and homogeneity of variances (F max test), and square root-transformed when premises for ANOVA were not met. One-way ANOVA (embryo development data; effect of astaxanthin) or two-way repeated-measures ANOVA (oocyte quality, and leukogram data; effect of astaxanthin, time, and interaction) followed by Tukey’s multiple comparisons test were performed using GraphPad Prism vs.7.0 (GraphPad Inc.). During the experimental period, animals were exposed to an average air temperature of 29.40±0.20°C and relative humidity of 58.00±0.80%. Physiological parameters were as follows: heart rate of 53.55±0.34 beats/min, respiratory rate of 48.39±0.31 breaths/min, body surface temperature of 32.83±0.11°C, and rectal temperature of 38.77±0.02°C. A higher white blood cell count was observed for the low AST group compared with control (P=0.0203) and high AST (P=0.0107) groups after 56 days of supplementation. For lymphocyte quantification, an effect of astaxanthin (P=0.0440) and astaxanthin×time of supplementation interaction (P=0.0239) were observed. The lower dose of astaxanthin caused an increase in lymphocyte number, which could be detected after 42 days of astaxanthin supplementation (P ≤ 0.05). No significant differences were detected for other leukocyte types. No effect of astaxanthin was observed on total number of oocytes recovered per cow except for the first OPU, in which more oocytes were retrieved from cows supplemented with 0.5 mg/kg per day of astaxanthin (9.92±1.95) compared with control (3.58±0.73; P=0.0179) and low AST (4.23±1.18; P=0.0358) groups. In addition, more viable oocytes (grades 1, 2, or 3 according to cytoplasm homogeneity and cumulus cells layers) were obtained from animals supplemented with 0.5 mg/kg per day of astaxanthin (3.17±0.39) compared with control (1.67±0.31; P=0.0050) and low AST (1.56±0.26; P=0.0022) groups. Interestingly, no differences were observed for invitro developmental potential among groups. These data suggest that a low dose of astaxanthin can affect lymphocyte mobilization, whereas a higher dose is required to improve the number of morphologically viable oocytes obtained by OPU from Holstein cows during summer.